Blog, Chirosecure Live Event December 11, 2021

Medicare ABN Updates

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Hi everyone. This is Sam Collins, your coding and billing expert for chiropractic and the HJ Ross company, giving you another update on the ChiroSecure live show. Welcome today. And let’s make sure we always keep things up to date and making sure that you’re not stuck with having issues where you don’t understand or people are trying to make it hard for you to understand. Do you ever notice the confusion? Sometimes we have in the profession where you hear someone saying, you’ve got to do this, you got to do that. And if you don’t do it, you’re going to go to jail. I mean, things with that much. So I’m always a little bit careful to make sure we have the right information. Obviously we do seminars, we have our network service, but we also have this program. We’re here to really make sure that you can be helped.

And that’s really what ChiroSecure is about. Making sure you have the right information to always make sure your practice can thrive. So let’s get forward and let’s get to the slides here. Let’s start talking about what’s going on now. I want to talk about an updates occurring with the ABN, the advanced beneficiary notice for Medicare. Now a couple of quick notes, just about Medicare. If you’re not aware of the Medicare deductible for next year, 2022 will be $233. So a little bit of an uptick there. Remember the deductible only applies for covered services, meaning in a chiropractic practice only for a manipulation. In addition, the Medicare fees appear to be being reduced between two to 4%, depending on your location. Hopefully Congress will vote before them. But as of now, we can expect about a two to 4% reduction. We’ll keep you up to date as to what changes there.

Well, this is what I want to focus in on the ABN advanced beneficiary notice. I like to make sure that we don’t get worked up into hyperbole. And what I mean by that is the exaggeration that people sometimes make. If you don’t do something, there’s going to be a tremendous problem. Remember all the things that people hype up. Remember when HIPAA first started, obviously it’s important, but at the same token, does it require you spend tens of thousands of dollars to be compliant? Well, the same thing applied with the ABN, the form did not change in October. Now the form was updated. The form did update. The new date of course is for June of 2023, but that updated actually in 2020, but got delayed because of COVID. What did update though, are some of the instructions for you? So be careful, the form is not any different.

What is updated is the way we use it in the instructions, for which, in my opinion, makes things a little bit easier for you. So I want to make sure we understand what these changes are. So the advanced beneficiary notice often referred to us CMS form 1 31 was revised and the new form indicates it. And you’ll know you’re using a new form. Look at the very bottom. It’ll have a revision date of June 30th, 2023. So very important to look at the bottom of your form because the reality is, if you look at the form that was before, it’s pretty much exactly the same. The only difference is the revision date, but you do have to use the new one. So make sure you have that updated version. This form is required for doctors of chiropractic. When the adjustment code, the CMT is not covered due to maintenance or just being a non-covered service.

Obviously it’s a covered service. And so when it’s not covered, we have to inform the patient it’s not covered because they become responsible. So the whole point of the advanced notices that we do this in advance of the treatment. So the patients aware of what the costs are going to be to them, the idea of it, and you’ll see it here in this fourth bullet, it helps the Medicare fee for service patient make an informed decision. I mean, no one wants a surprise. If you go to the doctor, assuming something is being paid and then it does not. And all of a sudden you owe it. You’re like, wait a minute. I didn’t know. Maybe I wouldn’t have gotten the care. In fact, we’ll do this on another show. When we talk about surprise billing, which is going to change next year, this is kind of the foreshadowing of that, that the patient has to be informed to before they get the care.

If they have to pay out of pocket. Now, remember if Medicare denies the visit and you did not give an ABN, you cannot charge the patient. So you want to start to really kind of look at well, how many visits is it for you? Do you find that Medicare denies you after 10, 15, 20, or 30, or at any point where you think it’s maintenance, you need to do this form because if you do not, and Medicare denies the claim. If you do not have an advanced beneficiary notice, you can not collect from the patient. Now, of course you can appeal to Medicare, but if you don’t win the appeal, we are stuck. We can’t charge the patient. So here’s the new form. And if you look at it, you’re going to go well, Sam, it really doesn’t look any different. It doesn’t the only differences. If you go to the very bottom, you notice the revision date is June 30th, 2023.

So what is the point of the form? The form is to give the patient information about their services and what they’re going to pay out of pocket. So how do you really use it? Well, the whole point of this form for chiropractic is about the chiropractic manipulate service of the spine. That is the only covered service by Medicare. And therefore really the only type of time we have to use it is when the adjustment is not being covered. Now, a lot of you may use this form otherwise, and we’ll talk about that in a moment. But the real purpose of the form is to inform the patient when the adjustment goat of the spine is not going to be covered and the patient is responsible. So the form itself, what you need to do is just fill it out in the way that it’s kind of intended.

So you’ll notice here at the top, it indicates CMT or adjustment. You can state that. And it says here that chiropractic spine manipulation 9, 8, 9, 4 1, and says, when Kara’s maintenance, not payable by Medicare, and you could put any statement, they’re not payable by Medicare, Medicare, doesn’t pay for this many visits, anything that indicates and clearly states the patient, it’s not payable. And then you indicate what the estimated costs will be. And we’ll talk about this in just a moment, because it doesn’t have to be the Medicare amount. The point of this form though, is that the patient in advance has been told that the services aren’t going to be covered and they’re going to be responsible. And the patient has given three choices and what’s important is making sure the patients understand what these three choices are. There is an option of one option. One says, I want the service, but I want you to bill Medicare.

The patient has a right for you to bill Medicare. If they choose to now, one thing I make important to patient understand, understand that once they sign this form, Medicare is not paying for it. The whole point of this form is that Medicare is not paying. We don’t use this form. If we go, I think they’re not going to pay either. It is, or it is not. If you think they’re not going to pay, that means they’re not going to pay. When you do this form, it means automatically Medicare is going to deny it. Cause that’s the point of it. So option one says, I want the service. I’m still gonna pay, but I want you to bill Medicare. So that, that way they get back a denial from Medicare. They want to see that denial like, oh yeah, it says here that I owe for it.

Now I would guarantee to the patient that once you sign this form, of course it’s not payable. Cause when you bill with the proper modifier, GA indicates it’s not payable, but the patient has a right to have it built. Now it’s important to make sure they understand I’m going to bill it for you, but it is going to be denied. So I don’t want you to have any misgivings that Medicare’s going to pay. I want you to know it’s going to be denied and you’ll get an EOB stating that, which says that they offer it. Now there is an option to, and this is the one I kind of prefer. And I’m sure you do too. Option two says I want the service, but do not bill Medicare. In other words, they kind of become basically a cash patient with the idea of being when they choose option two, they’ve understood, okay.

I know Medicare is not going to pay, so why am I going to bother having you bill for it? I’ll just pay for it. Now, a lot of patients may choose that option because they’re going well. What’s why do the hassle, your staff and the doctor have to do all this billing. Medicare has to process it, to tell us what we already know, which is they’re not going to pay. So Medicare has made this option available so that you don’t have to do the extra paperwork. If you will administratively to bill. If they choose option two, now clearly my preference less work, but don’t hassle it too much. If a patient goes, no, please bill, go ahead. Because you remember, there’s always going to be someone going, maybe they’re going to pay. Of course we know once they do the form, they’re not that’s the whole point, but the patient has a right to have it done.

So we can’t force them. By the way, if they choose option one, just bill, I would try to show them the benefits of option two, but we can’t force it. And then of course, there’s a third option. Notice the third option says, I do not want the service. In other words, you’re not forcing the patient. They may look and go, oh, if I have to pay for it, well, I can’t afford it. And therefore, no, I don’t want this service. And that’s acceptable too. Obviously we all get healthcare based on what we can afford. That’s kind of how our healthcare system works. Our healthcare system works on a fee for service. Either the person can or cannot afford it. And when they can’t, we can’t force them. So option three means I don’t want the service and there’s no billing. So when you’re really thinking of it, is this really that complicated a form.

What’s the point of this form is to simply inform the patient before the visit that it’s not going to be covered for a covered service, meaning spinal manipulation. However, this is where a lot of people I think use it for other reasons. You may also use it to inform about excluded services. So this format is always going to be about the covered service spine manipulation, but could you use this form to inform the patient, oh, Medicare is not going to cover therapies or examinations or things that aren’t spinal manipulation. You are welcome to use the form for that reason, but I will tell you I have a preference. I don’t really like that because this form is confusing at best. And if I use it once for covered, not covered services, and then later for a covered service, I think it’s often confusing. And if I put an excluded services says here, we’ll maybe it’s going to pay.

I want it to be clear that it’s not going to be payable. Now this form you can use for excluded services, but I’m going to make a simple recommendation. How about have a simple Medicare explanation of benefits or a simple Medicare form that explains the Medicare benefits. By example, notice this form, the deductible, and this is already set up for 2022 is $233. The next section forms about what Medicare coverage is. And you’ll see here. It says Medicare is only going to cover spinal manipulation and it’s underlying anything else you receive is going to be out of pocket. So what we’re trying to do is to make sure a patient’s really clear about what’s not covered. Now. Again, you could use an ABN to do that, but you can see the ABM becomes slightly confusing where there is no confusion here. Manipulation is the only thing covered.

Anything else you receive, whether it’s going to be exams, x-rays therapy, supplements are all out of pocket. My recommendation is to do a form like this with your Medicare patients, because often they have a lot of misunderstanding. I think of how many patients you’ve had that when they have Medicare, they say, oh good. I have Medicare now covers everything. And you’ve got to say, whoa, slow down. It doesn’t cover everything in a chiropractic office. It only covers spinal manipulation. The other services you may need and are required to have in some instances are not going to be covered. And I want that to be clear, make this something simple. Now you may think, well, Sam, where’s this form for members of our network service. Have you been to our seminars? This is a form as part of our document library, part of seminars, but certainly you can make up something simple in this format.

I recommend don’t confuse your Medicare patients. Make sure it’s clear to them. What is, and isn’t covered by using a form like this and say the ABN, what it’s intended for, which is to indicate when services aren’t covered that are normally covered. Now, one of the confusion that comes up though, is that there’s two versions of this form. Now the reality is there isn’t two versions, but there’s two ways of doing it. So take a look here apart. Provider uses a form just as you see it, by the way, if you go to the CMS website, you can download a complete listing of these forms, English, Spanish, small print, and large print. One of the formats also allows you to type into it, which I like, which it’s easy to do. If you’re a member of our service or have our document library, we have them already there for you.

So you can fill them out that way, but they are free on the Medicare site. So this is the one for par. It’s the standard, no changes. Just what you see. However, if you have a non-par provider, you know, if you’re registered as non-par, there’s a slight difference when it’s maintenance and you’ll notice here, I put red arrows. The last sentence of option one is crossed out and there’s additional information you have to put in section H about the service. What you’re basically doing is informing the patient that as a non-par, they’re still having to pay out of pocket. And it’s just a slight difference to make sure the idea is, or to make sure that the patient understands that it’s not going to be covered. What we want to be clear. The whole point of this form is to make sure the patient is aware.

It’s not covered. There’s no ambiguity. Once they have signed this form, it’s gotta be clear to them. They’re not going to pay. Remember, don’t use this form and bill with an 80, when you’ve done an ABN, it’s a GA that’s the modifier. And that modifier means the patient signed the waiver. Medicare automatically gives patient responsibility, do not combine GA and 80. And I know some of you think, well, I’ll do that because I’m not sure if Medicare’s going to pay, but I think it’s medically necessary. So you put an 80 in a GA. Well, they don’t accept that because you have to make a decision either it is or is not. Now, if you believe it is covered service or non maintenance, you have to bill with an 80. And if you aren’t able to prove that it was, let’s say they deny it, then you’re going to be stuck.

So I’m going to say, err, on the side of caution, I’m assuming you’re all familiar with the Medicare diagnostic categories. You know, if you’re using a category, a or simple codes, you’ve got to think of 12 visits or so, but if you’re in the category B section or moderate, probably 18 to 24, the category three, the more severe probably now 30 plus visits. Keep in mind. It’s not unusual for Medicare patients, particularly that have degenerative changes. They might have as much as 40 visits in a year. Maybe not all in one episode. So again, you have to judge based on, can I demonstrate that the patient is still getting better? If you can’t show that, then make sure they do an ABN. And that’s one of the things they’ve made an update to about the instructions is to make sure it’s clear that the patients get an understanding before.

So if you’re thinking Medicare is probably not going to cover, they’re not going to cover because there’s my point. We always think as chiropractors, oh, it should be covered. Care is corrective. But if you’re thinking Medicare is not going to cover lean towards their side because they chances are, they’re not now what about when they sign this form? Can I charge more? And this is something people are often confused by Medicare made an update to this in October as well in the Medicare claims processing manual section 50.9. It says very clearly when a beneficiary has been given a properly delivered, ABN the charge. And I put this in red, the charge may be the healthcare providers, usual customary fee for that item or service, not limited to Medicare fee schedule. Keep in mind if Medicare is not paying, it can be your regular fee. You just have to make sure to highlight that on the ABN, that instead of it being the Medicare rate of 45, it’s your regular rate of 65.

Now that comes down to kind of just your office and whether or not your office is one that can sustain where patients will pay. It could be your process, but the good news is it’s your choice. If you want to charge your regular rate, when it’s maintenance, you may, you may continue to charge the Medicare rate. Now, what I would say is just be conscientious. If you are charging your regular rate, then that’s what everyone should be paying. And if not, then the Medicare rate that really kind of comes down to your officer, are you in a more high-end area? Or are you more blue collar that may make the difference? But here’s the point. If Medicare is not paying it does not limit your fee. And I want to make sure everyone sees this clearly one to think about Medicare. They don’t make you guests.

So whenever you hear someone saying something for Medicare, always verify, well, where is it? Say it in the manual. So you can see here that manual indicates it. Now the thing that really updated was the timing, you know, understanding the timing of when to deliver. So the form must be done prior to the delivery of the service. You can’t go back later and say, Hey, Medicare denied this. And so I need you to sign this form that you accepted as being not medically necessary, that would not be properly done because that’s the whole point of it being an advanced notice. So always do it prior to the visit, not after the fact, if you do it after the fact, pretty much, if you, if you can’t win on appeal, you don’t do it. So you have to make sure you do it in advance. As soon as you think they’re not going to cover, have them sign an ABN.

And I would say, err, on the lesser, not the more my generic general rule would be. If you’re treating a patient for more than 60 days, chances are, if we look closely at your chart notes, it’s hard to discern that the patient is still getting better. So it may be seen as maintenance. Now, Medicare may still pay, but let’s say that’s later audited. That could be problematic. Don’t be afraid to error, maybe slightly more on the Medicare side because I don’t want to get caught later going, oh, we want it back. Now. The good news is Medicare. Doesn’t look that closely at it, but I want to be prepared to make sure that there’s going to be a clear evidence that the patient is improving. Now what’s the best clear evidence use an outcome assessment for that’s the easiest way. But bottom line is it has to be done before the service.

Remember the patients should be given this. You should sit with them and explain it and then offer a copy. Now, sometimes patients will say, I don’t want one and I get it, but you want to make sure they’re offered a copy. That way. There’s no issue of them going. I don’t remember. There’s a signed copy in their file and a copy they can take with them. Now, remember once they assigned it and I put it here, the CMT code gets a GA. The GA modifier only applies to covered services. So the GA modifier only applies for chiropractors with the three spinal manipulation codes. Never apply that to any other codes. Remember if it’s an excluded service, like a therapy that gets a G Y which means excluded service. The other thing that you have to know that’s changed. And I like this is that they do not need to sign a daily ABM.

And I, for those of you that have been around a long time, remember that form, you have to had to sign it every time they came in, they signed it and we had all the listing on the back. That’s no longer necessary. In fact, the old rule was it could be no longer than one year. Now what they’re saying is it can go longer than a year. So long as you highlight it, you have to indicate that this is a continuing care plan. And therefore it would continue for the next year and a half, two years, or until the ProCare plan changes. Now, I don’t think that’s going to be very common unless you have a patient that goes, doc. I just like getting treated once a week and they never have any flare ups, a new injury. Remember an ABN could happen after the patient’s 20th visit.

And they like coming in once a week. But then let’s say after about six or eight weeks, they hurt themselves again. And the care becomes acute. Then of course the ABN goes goodbye. And you start them with an acute care plan. And then once they go back to maintenance, then you would assign a new ABN. So remember always to update that. So just make sure you highlight the timing. It’s no longer limited to simply just a year. And in fact, some people didn’t know it was even a year. They’re thinking, I thought I had decided that every time, my goodness, no, you have them sign it once for the entire care plan. And that care plan if needed, could go beyond one year. So again, no requirement assigning daily. Now what if you have no GABM the patient didn’t sign one. That means you’re billing with an 18.

If you lose, you lose meaning you can appeal and don’t be afraid. Medicare will accept information to show if carers medically necessary, realize Medicare does look at care plans based on your diagnosis. And they have a set number of visits. They think are reasonable within a year. If you go beyond that, chances are they’re going to deny, but it doesn’t mean you can’t win. You’ll be surprised how many providers of my network service that we work on an appeal and we often win because let’s face it. How many Medicare patients have chronic underlying degenerative changes coupled on top of other conditions. These are not patients that this just happens once a year, but think of how many times they flare up 2, 3, 4 times a year. It’s not unusual for a Medicare patient to often get 40 plus visits in a year. Maybe not all on one episode, but at the same token, that number.

So if you’re thinking the care is maintenance, please make sure to have them sign. Because if you have no ABN and the care is denied, your only option is appealing and you cannot go after the patient. Remember the patient can not be held liable if they weren’t informed in advance that the services were not covered. So it’d be very, very conscientious. One of the things that’s occurring to that’s updated is what’s called a QMB qualified medical beneficiary. And I’m sure some of you are aware of this because this is a patient that has status, where they have Medicaid and Medicare. Now, if you have a PA, if you have as a provider only take Medicare and you get a patient also with Medicaid, they’re all there would be classified as a QMB this qualified medical beneficiary to our purpose means you may not collect money from the patient.

So keep in mind a qualified medical beneficiary is a patient that you will accept only what Medicare pays and cannot balance bill the patient, even for covered services. And that’s because we chose not to be part of Medicaid, which is your choice, but keep in mind, this is when you cannot collect the difference. So a QMB has outside rules of this, meaning you can’t collect even with an ABN, if it falls outside of the Medicare rule. So be very conscientious of these Medicaid, Medicare patients at the same token, though, think of it. You all have hardships. I would say a patient who is a QMB just by the very nature of having Medicaid and Medicare. That means they’re Medicare eligible, meaning there’ve been disabled or over 65, have a very limited income. That sounds to me like a patient with a hardships. I don’t have much of an issue of granting that because I’m sure you have other hardships.

The key factor here is abs don’t confuse yourself. It’s just a notice for a covered service when it’s not covered so that the patient’s held liable. The good news, how many Medicare patients have chronic recurring problems. Just remember if it reaches a point of maintenance to do so, but it’s not unusual for them to have multiple flare ups and the care may not need an ABN because of those types of flare ups. So don’t get confused. Don’t think, oh my God, I got to get a new form. Remember I just told you those forms are free on the Medicare side, Spanish English, large print and small print. They come in ones you can type into or just simply print. So don’t have to go out and buy anything. Now take a look on our website, the HJ Ross company, we have a new section. You’ll notice here, Medicare ABN update 2021.

If you haven’t already please go to our site like us on Facebook or even just a subscribed to our news section, because guess what we do with the HJ Ross company. Yeah, we do continuing education seminars. And when we do network services, but we also make sure you’re updated. Always have a source. You can go to that’s trusted. That’s not trying to sell you something else. Yes, we do seminars. We want to be there for you at the same token. We know that it’s best for us to give you more out, which means if I can give you information, chances are you’re going to go. You know what? That information was so good would be the right seminar. Do you ever notice how some seminars do this? It’s always a tease. What? I’m going to give you a new, I try to always make sure we do something well beyond that.

So you’ll notice here. Our new section has that. There’s just been an update to the Medicare fee schedule. Please take a look. We usually update something at least every other week, if not weekly. And we always have updates on Facebook that make it simple. So go to that page. But of course we do and want to be your resource. We offer a service called the network where I will be part of your office. Once you join, you can call me, email me, fax me on questions. It could be real simple. Hey Sam, can you take a look at this Medicare client? Make sure it’s right. Or I got a denial that said, CEO’s 16. We’re ready to do any. And all types of issues. We help you with that. The goal is every time you call, we make you more money. Cause it’s always about solving issues.

And remember, first of the year means there’s changes. So take a look at the resources. Here’s our website, HJ Ross company, our phone number, or always here to help. If you have any questions, don’t be afraid to reach out to us. Take a look. Also, we have our upcoming seminars. We’ll be live in some states. They will be live in virtual, but also live. That’s going to be fun. Getting back to where we’re at because some states remember are not going to allow virtual hours for all your hours. So we’re coming back there to first of the year as well. So I’m going to wish you all. Well, I’ll see you after the first of the year next week’s, um, host will be Janice Hughes. So I look forward for you to be with her and as always ChiroSecure and HJ Ross, we’re here to be your resource. Take care of everyone. I’ll see you next time.